DEPARTMENT OF VETERAN AFFAIRS

CONTRACT PROCESSING ACTION REQUEST (CPAR)

Please Do Not Complete Shaded Areas

/ 1. CONTRACT/ADMENDMENT PERIOD / 2. CONTRACT NUMBER
START DATE / END DATE
3. BILLIABLE PROGRAMS
PGM TITLE:
FUND SOURCE: / AMENDMENT NO.
()
4. DVA PROJECT MANAGER (Individual responsible for monitoring contract/expenditures) / PHONE / MAILSTOP
() / MS 41150
5. LEGAL NAME OF CONTRACTOR as reported to IRS
6. PRINCIPAL CONTACT. PLEASE USE NAME & TITLE OF THE PRIMARY VENDOR CONTACT FOR PURPOSES OF CONTRACT MANAGEMENT
NAME / TITLE / TELEPHONE NUMBER W/ AREA CODE / FAX NUMBER W/ AREA CODE / EMAIL ADDRESS
() / @
7. MAILING ADDRESS OF CONTRACTOR / CITY / STATE / ZIP CODE
8. WA UNIVERSAL BUSINESS IDENTIFIER / 9. FEDERAL EMPLOYER ID NO. OR SOCIAL SECURITY NO. / 10. CONTRACTOR STATUS (IRS 1099)
SOLE PROPRIETOR
LLC
PARTNERSHIP
CORPORATION
NON-PROFIT
GOVERNMENTAL
LLP
OTHER / 13. CHECK APPLICABLE BOX
Type Contract:
Goods and Services
Client Services
Interagency Agreement
Professional Services
Information Tech Agreement
Grant
Other:
Certification: (OMWBE/Veteran)
OMWBE Minority Owned Business
OMWBE Women Owned Business
Minority/Women Owned Business
Veteran Owned Business
Small/Micro/Mini
10A. CONTRACTOR STATUS (W-9) CONTINUED
W-9 RECEIVED? YES NO
SWV ______- __ __
11. CHECK APPLICABLE BOX
CONTRACT
CONTRACT AMENDMENT / 12. DES WEBS STATUS: WDVA requires COMPANY/CONTRACTOR to be registered in DES WEBS. Is COMPANY/CONTRACTOR registered?
YES NO N/A DATE REGISTERED:
If not, have them register at: http://www.des.wa.gov/services/ContractingPurchasing/Business/Pages/WEBSRegistration.aspx
14. describe the service/goods to be provided by the contractor or the purpose of the amendment
attach detailed scope of work with deliverables expected.
See attached.
15. above funding includes STATE AND federal funds
YES NO a. If yes, enter amount or percent of federal funds and source…..………………….
b. If yes, enter amount or percent of state funds and source……...………………… / $ /%
$ /%
16. EXPLAIN WHY THIS SERVICE CANNOT BE PERFORMED BY PERSONNEL OF DVA OR PERSONNEL OF ANOTHER WASHINGTON STATE GOVERNMENT AGENCY
17. account code to be charged on expenditure documents
MASTER INDEX / SUB OBJ & SUB SUB OBJ / % OF PROG FUNDING / CONTRACT AMOUNT / Amendment amount
(To be completed only if you AMENDING an existing contract) / BUDGET AUTHORITY (Authorizing Signature, may be more than one individual if multiple programs are contributing funds)
I hereby authorize the initiation of the contract/amendment referenced above. I certify that funds are obligated and available for payment of services described herein.
Signature goes in below column / Print or Type Name in Below Column
/ /

%

/

$0

/

$0

/ /

Name:

Title:

% / $0 / $0 / Name:
Title:
$ 0.00 / $ 0.00 / Accumulative total maximum amount of contract: / $ 0.00
CONTRACTS MANAGER / DATE OF SIGNATURE APPROVAL / SIGNATURE APPROVAL
Wadell Brent / //

DVA FORM C-001 (ELECTRONIC Revised 08/2016)